Involuntary Patients Research Articles

Perceived coercion in persons with mental disorder in India: A cross-sectional study.

Background:Little is known about how patients in India perceive coercion in psychiatric care.Aims:To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables.Materials and Methods:We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used.Results:Three hundred and one patients participated. “Perceived coercion” subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. “Negative pressure” increased with male gender, extended family, lower income, forensic history, and longer illness duration.Conclusions:The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.

Legal criteria for involuntary mental health admission: clinician performance in recording grounds for decision.

Mental health laws set criteria that limit the use of involuntary admission to specific circumstances, and clinicians are expected to justify the lawfulness of such detention by referral to these criteria. The South Australian Mental Health Act 1993 required grounds to be documented on the detention form, specifically with respect to the presence of a mental illness, risk to self or others, and a need for immediate treatment. This investigation sought to determine whether the grounds provided for detention met legislative requirements. 2491 consecutive forms authorising the initial detention of involuntary patients in South Australia between July 2008 and June 2009 were rated to determine whether criteria stipulated by legislation were addressed. Only 985 forms (40%) addressed all the legal requirements for detention. 1471 forms (59%) did not comment on a requirement for immediate treatment, 540 (22%) did not state the presence of mental illness, and 359 (14%) did not discuss risk to self or others. Given the particularly poor performance of clinicians in addressing the need for immediate treatment, the data was reanalysed with respect to the presence of mental illness and risk only; 1697 forms (68%) addressed both these criteria. This low compliance rate with legal requirements is concerning. It may reflect clinical decision making, the attention given to the form by the physician filling it, or a combination of both. Stating the grounds for involuntary admission should provide protection for the rights of patients, and the requirement to do so reflects the gravity that the loss of liberty entails for the patient. Our findings are relevant to jurisdictions that are currently reviewing mental health legislation and the need to document the grounds for involuntary treatment, including South Australia.

Can We Have Routine Measurement of Patient Satisfaction in Acute Psychiatric Settings? A Cross Sectional Study

Patient satisfaction is considered an important indicator of the quality of care in psychiatric services. Its importance has been widely studied, but the literature identifies methodological problems deriving from samples with low response rates and exclusion criteria which would seem to imply a kind of exclusion in the evaluations of less compliant patients. The aim of this study is to test a methodology to assess patient satisfaction with the quality of care received at an acute psychiatric ward in terms of its application in daily routine. In this cross sectional survey inpatients were given the Rome Opinion Questionnaire (ROQ). Our patients, involuntary patients included, with a 92.3% participation rate (47 patients out of 51), returned a mean general satisfaction score of 7.7/9.This response rate is higher than that reported in most previously published studies, which shows that a good level of both voluntary and involuntary patient participation may be achieved when an appropriate methodological approach is adopted. Not acknowledging patient satisfaction reduces the possibility of more effective caring actions. Measuring patient satisfaction, through use of short questionnaires, should become a routine in daily practice.

"Boarding" Psychiatric Patients in Emergency Rooms: One Court Says "No More".

"Boarding" involuntary psychiatric patients in medical emergency rooms is common in many parts of the United States. The practice, driven by a shortage of alternative resources, including limited inpatient capacity, can result in patients' being held for days without treatment or a hospital room, often in busy corridors or treatment rooms. A recent challenge to this practice led the Washington Supreme Court to declare it illegal and resulted in the appropriation of substantial funding to create new psychiatric beds. Centralized psychiatric crisis services, with appropriate payment models, may offer another approach to reducing the need for holding patients awaiting inpatient admission.

Prevalence and Risk Factors of Violence by Psychiatric Acute Inpatients: A Systematic Review and Meta-Analysis.

BackgroundViolence in acute psychiatric wards affects the safety of other patients and the effectiveness of treatment. However, there is a wide variation in reported rates of violence in acute psychiatric wards.ObjectivesTo use meta-analysis to estimate the pooled rate of violence in published studies, and examine the characteristics of the participants, and aspects of the studies themselves that might explain the variation in the reported rates of violence (moderators).MethodSystematic meta-analysis of studies published between January 1995 and December 2014, which reported rates of violence in acute psychiatric wards of general or psychiatric hospitals in high-income countries.ResultsOf the 23,972 inpatients described in 35 studies, the pooled proportion of patients who committed at least one act of violence was 17% (95% confidence interval (CI) 14–20%). Studies with higher proportions of male patients, involuntary patients, patients with schizophrenia and patients with alcohol use disorder reported higher rates of inpatient violence.ConclusionThe findings of this study suggest that almost 1 in 5 patients admitted to acute psychiatric units may commit an act of violence. Factors associated with levels of violence in psychiatric units are similar to factors that are associated with violence among individual patients (male gender, diagnosis of schizophrenia, substance use and lifetime history of violence).

The Low Proportion and Associated Factors of Involuntary Admission in the Psychiatric Emergency Service in Taiwan.

BackgroundThe involuntary admission regulated under the Mental Health Act has become an increasingly important issue in the developed countries in recent years. Most studies about the distribution and associated factors of involuntary admission were carried out in the western countries; however, the results may vary in different areas with different legal and socio-cultural backgrounds.AimsThe aim of this study was to investigate the proportion and associated factors of involuntary admission in a psychiatric emergency service in Taiwan.MethodsThe study cohort included patients admitted from a psychiatric emergency service over a two-year period. Demographic, psychiatric emergency service utilization, and clinical variables were compared between those who were voluntarily and involuntarily admitted to explore the associated factors of involuntary admission.ResultsAmong 2,777 admitted patients, 110 (4.0%) were involuntarily admitted. Police referrals and presenting problems as violence assessed by psychiatric nurses were found to be associated with involuntary admission. These patients were more likely to be involuntarily admitted during the night shift and stayed longer in the psychiatric emergency service.ConclusionsThe proportion of involuntary admissions in Taiwan was in the lower range when compared to Western countries. Dangerous conditions evaluated by the psychiatric nurses and police rather than diagnosis made by the psychiatrists were related factors of involuntary admission. As it spent more time to admit involuntary patients, it was suggested that multidisciplinary professionals should be included in and educated for during the process of involuntary admission.

New Croatian Law On Protection of Persons with Mental Disorders in Comparison with Mental Health Acts Across Europe: Do We Have a Different View On Human Rights?

Introduction Croatia is introducing the new Law on Protection of Persons with mental disorders on January 1, 2015. Major changes are related to the terms of involuntary admissions, thus aiming to improve protection of persons with mental disorders within psychiatric care. Aim Aim of this paper is to compare mental health legislation and position of mentally ill people in five EU countries, namely Croatia, Germany, Spain, Sweden and UK. Methods Methods of descriptive analysis are employed to explore similarities and differences among countries in relation to the four following indicators - involuntary admission procedure, forms of involuntary treatment, maximum duration of involuntary treatment and patients' legal right to complain. Results Despite all being in the EU, countries included in the study vary substantially in their legislation for the practice of involuntary hospital admission which will be presented in details. Conclusion How involuntary treatments should be legislated and regulated is highly controversial. We believe that EU countries should join forces to create a common understanding of this issue because legal differences could lead to substantial discrepancies in human right protection practices regarding persons with mental disorders.

Rate of involuntary admission in Dublin South West: a 5-year retrospective review.

International figures for involuntary admissions vary widely. Differences in legislation, professionals' ethics and public attitudes towards risk have been known to influence this rate. Comparing involuntary admission rates in different parts of the same country can help control for variability found between international studies. This study assessed the rates of involuntary admissions in the Dublin South West Mental Health Service compared with the rest of Ireland. We examined the demographic and clinical profiles of all involuntary patients admitted to the acute psychiatric inpatient unit in Tallaght Hospital between 2007 and 2011. We compared the rate of admission in Tallaght with the rest of Ireland. Data gathered included all patients detained on Form 6 and Form 13 (change of status) looking at age, gender, diagnosis and number of patients who had a Mental Health Tribunal. Form 7 (renewal orders) was also examined We calculated the rate per 100 000 population per year of Form 6 admissions, Form 13 and Form 7 (certificate and renewal order by responsible consultant psychiatrist) using figures from the 2006 Census. All data were analysed using SPSS. The rate of involuntary admission in Tallaght Hospital was significantly lower compared with the rest of Ireland (Form 6: t=-11.2; p<0.001, Form 13: t=-3.1; p=0.04, Form 7: t=-13.9; p=0.001). This difference was evident for all methods of involuntary detention and was also the case for Form 7 (renewal orders). Mental Health Tribunals were held for 59% of patients, a rate comparable with earlier findings described in publications, following the introduction of the new Mental Health Act. Rates per 100 000 population were lower in Dublin South West compared with the rest of Ireland. The reasons for this are not clear. Further research comparing similar services in Ireland could explain these findings.

Tensions and Risks in the Blanket Use of Locked Door Policies in Acute Mental Health Inpatient Facilities: Balancing Human Rights, Clinical Utility and Public and Patient Protection

Although there has been a consistent trend away from institutionalised mental health care over the past decades, this has occurred at the same time as increased coercive care measures are employed in mental health inpatient facilities, as these facilities become weighted to more serious cases. Locked wards, which regulate the ability of both voluntary and involuntary patients to leave psychiatric units, are increasingly common in acute mental health inpatient settings. This article focuses on the controversy surrounding a recent initiative to extend locked door policies across all public acute inpatient facilities in Queensland, explores the legal, ethical and clinical issues around the implementation of locked door policies in acute mental health inpatient facilities, and examines the tensions in balancing individual rights and public and personal protections in the treatment of acute mental health disorders.

A systematic review of the frequency, duration, type and effect of involuntary treatment for people with anorexia nervosa, and an analysis of patient characteristics.

ObjectiveInvoluntary treatment of anorexia nervosa is controversial and costly. A better understanding of the conditions that determine involuntary treatment, as well as the effect of such treatment is needed in order to adequately assess the legitimacy of this model of care. The aim of the present study was to investigate the frequency and duration of involuntary treatment, the characteristics of this group of patients, the kind of involuntary actions that are applied and the effect of such actions.ReviewRelevant databases were systematically searched for studies investigating the involuntary treatment of individuals diagnosed with anorexia nervosa.ResultsThe studies included in the review contained people treated in an inpatient setting for severe or severe and enduring anorexia nervosa. People that were treated involuntarily were characterised by a more severe psychiatric load. The levels of eating disorder pathology between involuntary and voluntary groups were similar and the outcome of involuntary treatment was comparable in terms of symptom reduction to that of voluntary treatment.ConclusionDespite inconsistent findings, the comparable levels of eating disorder pathology observed between involuntary and voluntary patient-groups together with findings of higher co-morbidity, more preadmissions, longer duration of illness and more incidences of self-harm for involuntary patients suggest that involuntary treatment is not a reaction to the severity of eating disorder symptoms alone, but is most likely a response to the complexity of the patient’s situation as a whole.

Short-Term Hospitalization Underlies the Similarity between Involuntarily and Voluntarily Admitted Patients: A One-Year Cohort Study

ABSTRACTThis study compared individuals admitted to a psychiatric hospital under a civil involuntary commitment order (IA) and patients admitted voluntarily (VA) using a one-year, shortest-stay cohort. Data were collected for 439 patients consecutively admitted to a university-affiliated Mental Health Center from March 1, 2012, to February 28, 2013, and discharged within seven days (one-year, shortest-stay cohort). A cross-sectional comparison between IA (n = 106) and VA (n = 333) groups was conducted. Mean length-of-stay was found to be slightly longer (4.7 ± 1.7 days) for the IA group compared to the VA group (3.8 ± 1.9 days; p = 0.019). Both IA and VA groups were similar regarding age, gender, marital status, age of onset, illness duration, and diagnosis. An acute psychotic state as reason for admission was observed 3.4 times more (p < 0.001) for IA compared to VA, whereas suicidal thought (p = 0.002), major depressive episode (p < 0.001), and hallucinations (p = 0.014) were found less frequently among IA patients. About one quarter of the patients (26.6 percent) in the study cohort were discharged for lack of adequate reason to remain hospitalized. There were no significant differences between IA and VA inpatients. The shortest length of stay underlies the similarity between involuntarily and voluntarily admitted patients. The obtained data point toward the need for more accurate assessment of the criteria for involuntary admission.

Are psychiatric team meetings patient centred? A cross-sectional survey on patient views regarding multi-disciplinary team meetings.

The system of weekly psychiatric ward rounds is being challenged and multi-disciplinary team meetings (MDTMs) involving inpatients have been developed. These aim to improve integration between medical and social services and increase patient involvement in their care. However, such large meetings are potentially threatening to the patient. This survey aimed to examine inpatient experience of MDTMs and identify factors that significantly alter this experience. In this cross-sectional survey we assessed patient opinion regarding patient inclusive MDTMs in a psychiatric inpatient unit. A total of 27 participants (response rate 90%) were included. We utilised descriptive statistics and Fisher's exact test for non-parametric data where appropriate. In all, 85% (n=23) of patients identified the consultant psychiatrist as a member that they would like to have present at the MDTM. The ward nurse was identified by 63% (n=17) of patients. In all, 48% (n=13) of patients reported feeling anxious/threatened at the MDTM. In all, 70% (n=19) of patients stated that they would have felt less threatened at the MDTM if there were fewer people in attendance. A significant number of voluntary patients (n=11) felt threatened/anxious at the MDTM compared with involuntary patients (n=2) (χ 2=4.921, df=1, p=0.026). The central findings of this study are that patients would prefer fewer people at the MDTM and would feel less threatened/anxious if they participated in selecting those in attendance. These findings suggest that greater patient involvement in preparation for the MDTM could result in a less anxiety filled experience for them.

Decreased platelet serotonin concentration in Alzheimer's disease with involuntary emotional expression disorder

Alzheimer's disease (AD) is a progressive neurodegenerative disorder manifested by progressive decline in cognitive functions. A variety of behavioral disturbances appear very often in AD which might be associated with altered function of serotoninergic system. The aim of the study was to determine platelet serotonin (5-HT) concentrations in 49 patients with AD (NINCDS-ADRDA and DSM-IV-TR criteria) subdivided in three groups: (a) patients with aggressive behavior, (b) patients with involuntary emotional expression disorder (IEED) and (c) patients without aggression or IEED (controls). Platelet 5-HT concentrations were measured using ELISA. Platelet 5-HT concentrations were significantly lower in patients with AD and co-existing IEED compared to AD patients with aggressive behavior or control patients. No significant difference in platelet 5-HT concentrations was found between patients expressing aggressive behavior and controls. Our results suggest disruptions in serotoninergic system in AD patients with comorbid IEED but not with aggressive behavior and support the presumption that platelet 5-HT concentration is a suitable and easy measured peripheral indicator of some behavioral and psychological symptoms of AD.

We need to talk about depot: effect of Community Treatment Order on depot antipsychotic medication compliance.

The current study compares the compliance rates of patients on depot who were on Community Treatment Orders with those who were not on such Order with a view to objectively quantify the effect of Community Treatment Orders on depot antipsychotics medication compliance. "Day difference" measurements between the scheduled depot data and the administered date were collected for both voluntary and involuntary patients receiving depot medication at the same community clinic over a 6-month period. The results demonstrated a trend for greater compliance to depot medications by those not on a Community Treatment Order compared with those who were, but there was no statistically significant difference between the two groups. The current study highlighted that while Community Treatment Order may be a reasonable short-term tool to encourage patients' compliance at an early treatment stage, ongoing effort should be put into improving patients' attitude towards depot medications to ensure a better long-term outcome for individuals with schizophrenia.

Rehospitalization risk of former voluntary and involuntary patients with schizophrenia.

The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization. In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %) involuntarily. Follow-up assessments were conducted half-yearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a random-effect logit model and a random-effect tobit model. After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer. Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients.

Focused opportunities for resident education on today's inpatient psychiatric units.

The functions and nature of inpatient psychiatric units have changed dramatically over recent decades, as has the role of psychiatric residents on these units. Nonetheless, clinical rotations on inpatient psychiatry remain as core clinical experiences in psychiatric residency. This column reviews the key changes in the residents' inpatient experience and articulates appropriate educational goals for current inpatient rotations in the areas of the psychiatric interview, diagnosis and formulation, treatment planning, working as a member of a multidisciplinary team, and working with acutely ill and involuntary patients.

Involuntary detention and treatment of the mentally ill: China's 2012 Mental Health Law

The long-awaited Mental Health Law of China was passed on 26 October 2012 and took effect on 1 May 2013. Being the first national legislation on mental health, it establishes a basic legal framework to regulate mental health practice and recognizes the fundamental rights of persons with mental disorders. This article focuses on the system of involuntary detention and treatment of the mentally ill under the new law, which is expected to prevent the so-called “Being misidentified as mentally disordered” cases in China. A systematic examination of the new system demonstrates that the Mental Health Law of China implicitly holds two problematic assumptions and does not provide adequate protection of the fundamental rights of the involuntary patients. Administrative enactments and further national legislative efforts are needed to remedy these flaws in the new law.

Are Reports of Cognitive Testing Among Older Electroconvulsive Therapy Recipients Clinically Valid?

Electroconvulsive therapy (ECT) administration rises in frequency with age, with older depressed adults often showing clinical features predictive of good response. Recent reviews suggest that older people experience few if any long-term cognitive adverse effects after contemporary ECT, despite their increased vulnerability to these. However, the broader clinical validity of research findings is not assured as most studies of ECT-related cognitive effects do not discuss cognitive test nonparticipants. This study examines whether cognitive test participants and nonparticipants are comparable. We recently completed a study of cognition in depressed patients 65 years and older treated with ECT. Only 35% of eligible patients completed neuropsychological testing at 2 time points, the remainder either refusing or unable to consent. To examine whether exclusion of most eligible patients from cognitive testing might have affected the clinical applicability of findings, we compared demographic and clinical characteristics of patients who participated with those who did not based on a subset of patients from our original study. The 2 patient groups differed in several respects. Most notably, nonparticipants were significantly more likely to be involuntary patients; to refuse food and fluids; and to require treatment with a bitemporal or mixed electrode placement. Our findings suggest cognitive test nonparticipants to be more severely psychiatrically unwell than test participants. As their exclusion might bias results and confound understanding of this important ECT-related topic, special mention of participation rates and comparison of participants and nonparticipants is recommended to establish the clinical relevance of future study findings.

Mental Capacity in Patients Involuntarily or Voluntarily Receiving Psychiatric Treatment for an Acute Mental Disorder

Despite the growing amount of data, much information is needed on patients' mental capacity to consent to psychiatric treatment for acute mental disorders. The present study was undertaken to compare differences in capacity to consent to psychiatric treatment in patients treated voluntarily and involuntarily and to investigate the role of psychiatric symptoms, competency, and cognitive functioning in determining voluntariness of hospital admission. Involuntary patients were interviewed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the 24-item Brief Psychiatric Rating Scale (BPRS), the Mini Mental State Examination (MMSE) and the Raven's Colored Progressive Matrices, and their data were compared with those for age- and sex-matched voluntary patients. Involuntary patients performed worse in all MacCAT-T subscales. Capacity to consent to treatment varied widely within each group. Overall, involuntary patients have worse consent-related mental capacity than those treated voluntarily, despite capacity to consent to treatment showing a significant variability in both groups.

Increased cardiovascular risk in patients with severe mental illness

People with severe mental illness (SMI) have a reduced life expectancy. A major cause of mortality is cardiovascular disease. The aims of this study were to document the prevalence of cardiovascular risk factors in people with SMI engaged in community psychiatric rehabilitation and compare prevalence rates to the general, and Aboriginal and Torres Strait Islander (ATSI) populations of Australia. A cross-sectional audit was conducted on patients receiving care from Melbourne's Inner-West Area Mental Health Service. Profiles were collected on: smoking status, body mass index, waist circumference, blood pressure, diabetic status and fasting lipid profiles. These were compared with the general and ATSI Australian populations. Complete data were available for 60 patients. Most were involuntary patients with a diagnosis of schizophrenia or schizoaffective disorder. Patients were more likely to smoke, be obese, have dyslipidaemia and the metabolic syndrome compared with the general and ATSI populations of Australia. Patients were more likely to have diabetes than the general population but had similar rates to the ATSI population. Patients had similar rates of hypertension to the general population but were less likely to be hypertensive compared with the ATSI population. Australians living with SMI have very high rates of cardiovascular risk factors, far in excess of the general Australian population and comparable with the ATSI population.